Healthcare Provider Details

I. General information

NPI: 1447952296
Provider Name (Legal Business Name): ALEXANDRA JADE STARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 BREMO RD STE 111
RICHMOND VA
23226-2443
US

IV. Provider business mailing address

1321 MCDONOUGH ST UNIT B
RICHMOND VA
23224-2143
US

V. Phone/Fax

Practice location:
  • Phone: 804-918-1115
  • Fax:
Mailing address:
  • Phone: 571-480-0365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0734008716
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: